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The Preventive Effect of the Nordic Hamstring Exercise on Hamstring Injuries in Amateur Soccer
Players: A Randomized Controlled Trial
Nick van der Horst, Dirk-Wouter Smits, Jesper Petersen, Edwin A. Goedhart and Frank J.G. Backx
Am J Sports Med published online March 20, 2015
DOI: 10.1177/0363546515574057
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What is This?
Background: Hamstring injuries are the most common muscle injuries in soccer, and they have a high rate of recurrence. Eccen-
tric hamstrings strength is recognized as an important modifiable risk factor. This led to the development of prevention exercises
such as the nordic hamstring exercise (NHE). The effectiveness of the NHE on hamstring injury prevention has never been inves-
tigated in amateur soccer.
Purpose: To investigate the preventive effect of the NHE on the incidence and severity of hamstring injuries in male amateur soc-
cer players.
Study Design: Randomized controlled trial; Level of evidence, 1.
Methods: Male amateur soccer players (age, mean 6 SD, 24.5 6 3.8 years) from 40 teams were randomly allocated to an inter-
vention (n = 20 teams, 292 players) or control group (n = 20 teams, 287 players). The intervention group was instructed to perform
25 sessions of NHE in a 13-week period. Both the intervention and control groups performed regular soccer training and were
followed for hamstring injury incidence and severity during the 2013 calendar year. At baseline, personal characteristics (eg,
age, injury history, field position) were gathered from all participants via a questionnaire. Primary outcome was injury incidence.
Secondary outcomes were injury severity and compliance with the intervention protocol.
Results: A total of 38 hamstring injuries were recorded, affecting 36 of 579 players (6.2%). The overall injury incidence rate was
0.7 (95% CI, 0.6-0.8) per 1000 player hours, 0.33 (95% CI, 0.25-0.46) in training, and 1.2 (95% CI, 0.82-1.94) in matches. Injury
incidence rates were significantly different between the intervention (0.25; 95% CI, 0.19-0.35) and control groups (0.8; 95% CI,
0.61-1.15), x2(1, n = 579) = 7.865; P = .005. The risk for hamstring injuries was reduced in the intervention group compared with
the control group (odds ratio, 0.282; 95% CI, 0.110-0.721) and was statistically significant (P = .005). No statistically significant
differences were identified between the intervention and control groups regarding injury severity. Compliance with the intervention
protocol was 91%.
Conclusion: Incorporating the NHE protocol in regular amateur training significantly reduces hamstring injury incidence, but it
does not reduce hamstring injury severity. Compliance with the intervention was excellent.
Keywords: hamstring injuries; soccer; injury prevention; eccentric strengthening; nordic hamstring exercise; nordic curl
Soccer is the most popular sport in the world, with more Hamstring injuries are the most common soccer-related
than 275 million participants.16 Unfortunately, research muscle injury.11,39,44 They account for 37% of all soccer
on sports injuries show high injury incidence rates for soc- muscle injuries, requiring extensive treatment and long
cer, with male amateur soccer players being particularly rehabilitation periods.11,20,39,44 Recurrence rates for ham-
prone to injury.9,10,12,35,38,43 Injury incidence rates of 20.4 string injuries remain high (12%-33%) despite preventive
to 36.9 injuries per 1000 match hours and 2.4 to 3.9 inju- measures.20,21,23,44 Multiple potential risk factors for ham-
ries per 1000 training hours have been reported in male string injuries have been reported, such as age, player
amateur soccer.28,38,41 position, previous hamstring injury, muscle architecture,
fatigue, flexibility, core stability and strength.6,13,18,22,30,40
The nordic hamstring exercise (NHE), or nordic curl,
has been shown to be an effective tool to increase eccentric
The American Journal of Sports Medicine, Vol. XX, No. X
DOI: 10.1177/0363546515574057 hamstring strength, developing higher maximal eccentric
Ó 2015 The Author(s) hamstring strength torques when compared with regular
1
Downloaded from ajs.sagepub.com at GEORGIAN COURT UNIV on March 23, 2015
2 van der Horst et al The American Journal of Sports Medicine
Randomization Procedure
METHODS Soccer teams were used as the unit of cluster to avoid the
risk of bias if individuals were randomized to the interven-
Study Setting tion program. After computer-generated random assign-
ment of team numbers, an equal number of teams were
The present study was a cluster-randomized controlled tri- randomized to the control or intervention group by an
al, carried out in collaboration with the Royal Netherlands online research randomizer (http://www.randomizer.org).
Football Association (KNVB). Soccer teams from 4 geo-
graphically separated districts playing in high-level ama-
teur field soccer competition (KNVB Eerste Klasse) were Intervention
invited to participate. These teams generally play 1 and
sometimes 2 matches a week, with 2 or 3 training sessions Nordic Hamstring Exercise. The NHE, also referred to
per week. Dutch high-level amateur soccer teams generally as the nordic curl, is designed to improve eccentric strength
have a physical therapist present at all matches and train- of the hamstring muscles.31 The exercise is performed in
ing. Occasionally, a sports massage therapist is present at pairs (Figure 1; see also the Video Supplement).33
matches and training, with a physical therapist available Players start in a kneeling position, with the torso from
for additional consulting in case of any injury. The trial the knees upward held rigid and straight. The training
was approved by the medical ethics committee of the Uni- partner ensures that the player’s feet are in contact with
versity Medical Centre Utrecht (file No. 12-575/C) and reg- the ground throughout the exercise by applying pressure
istered in the Dutch trial register (NTR3664) as the HIPS to the player’s heels/lower legs. The player then lowers
(Hamstring Injury Prevention Strategies) study. More his upper body to the ground, as slowly as possible to max-
detailed information is available in the study protocol.24 imize loading in the eccentric phase. Hands and arms are
used to break his forward fall and to push him back up
after the chest has touched the ground, to minimize load-
Eligibility Criteria ing in the concentric phase.31
Exercise Procedures. For the purpose of the present
Dutch male amateur soccer players aged 18 to 40 years study, the exercise was supervised by the team coach or
were eligible for inclusion. Players who joined a participat- medical staff (eg, physical therapist and/or sport masseur).
ing team after the start of the trial were not included. All Exercises took place immediately after the completion of
players were informed using an information letter and normal training, as recommended by Small et al,36 before
asked to give their informed consent before the start of cooling down. After the winter break in the 2012-2013 sea-
this study. Players unwilling to do so were excluded from son (last 2 weeks in December), all teams started their nor-
the trial. mal training program about 3 to 5 weeks before the
*Address correspondence to N. (Nick) van der Horst, Department of Rehabilitation, Nursing Science & Sports, University Medical Center Utrecht, Hei-
delberglaan 100, Utrecht, UT 3584CX, the Netherlands (e-mail: n.vanderhorst-3@umcutrecht.nl).
y
Department of Rehabilitation, Nursing Science & Sports, University Medical Center Utrecht, Utrecht, the Netherlands.
z
Arthroscopic Center Amager, Copenhagen University Hospital, Hvidovre, Copenhagen, Denmark.
§
FIFA Medical Center, Royal Netherlands Football Association, Zeist, the Netherlands.
One or more of the authors has declared the following potential conflict of interest or source of funding: This study is funded by the Netherlands Orga-
nization of Health Research and Development (ZonMW 50-50310-98-152) and the Royal Netherlands Football Association (KNVB).
Assessed for
Enrollment eligibility
(n = 110 teams)
Excluded
- No response (n = 32 teams)
- Declined to participate (n = 38 teams)
Randomised
(n = 40 teams)
Analysed Analysed
(n = 16 teams; n = 292 players) Analysis (n = 16 teams; n = 287 players)
per team as follows: (amount of NHE sessions) / 25 3 100 = differences between match or training exposure between
% compliance. the intervention and control groups (Table 3).
TABLE 2
Baseline Characteristics of Soccer Players in Intervention and Control Groupsa
a
Values are presented in mean 6 SD or percentage (No.).
TABLE 3
Comparison of the Intervention and Control Groupsa
a
Values are presented in mean 6 SD or No.
b
Significantly different between the intervention and control groups (P \ .05).
c
After the end of the intervention period (weeks 13-52).
After the intervention period, 18 hamstring injuries Effects of the Intervention on Injury Severity
(72%) were recorded in the control group and 6 (55%) in
the intervention group, showing a significant difference After the intervention period, players in the intervention
in hamstring injuries between both groups, x2(1, n = 579) and control groups were absent from soccer play for an
= 7.865, P = .005. Risk for injuries was reduced in the inter- average (6SD) of 31 6 15 days and 28 6 19 days, respec-
vention group after performing the NHE protocol (relative tively. The difference in injury severity between the inter-
risk, 3.384; 95% CI, 1.362-8.409) (odds ratio, 0.282; 95% CI, vention and control groups was not statistically significant:
0.110-0.721) and was statistically significant (P =.005). t(22) = .374, P = .342.
same performance level, had approximately similar train- 5. Chumanov ES, Heiderscheit BC, Thelen DG. Hamstring musculoten-
ing and match exposure, and were randomized by an inde- don dynamics during stance and swing phases of high-speed run-
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pendent randomizer, we assumed similar intensity
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costs, and personal suffering of the injured player.15 The Crielaard JM. Hamstring muscle strain recurrence and strength per-
NHE has proven to be an effective preventive measure for formance disorders. Am J Sports Med. 2002;30(2):199-203.
hamstring injuries in soccer.1,33 Unfortunately, positive out- 8. Croisier JL, Ganteaume S, Binet J, Genty M, Ferret JM. Strength
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vent injuries only when they are adopted and used by the 9. Dvorak J, Junge A. Football injuries and physical symptoms: a review
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in collaboration with the Royal Netherlands Football Associ- 10. Ekstrand J. Epidemiology of football injuries. Sci Sports. 2008;23:
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This collaboration, as well as the specific parameters and
in professional football (soccer). Am J Sports Med. 2011;39(6):
buildup of the intervention protocol, should provide a basis 1226-1232.
for implementation of the NHE in soccer training for Dutch 12. Ekstrand J, Hägglund M, Waldén M. Injury incidence and injury pat-
amateur teams. Policy makers and football associations terns in professional football: the UEFA injury study. Br J Sports Med.
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gate implementation of injury preventive strategies such as 13. Engebretsen AH, Myklebust G, Holme I, Engebretsen L, Bahr R.
Intrinsic risk factors for hamstring injuries among male soccer play-
the NHE to make injury prevention truly work.
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implementation and effectiveness of injury preventive strat- 14. Engebretsen AH, Myklebust G, Holme I, Engebretsen L, Bahr R. Pre-
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positive study outcomes do not directly translate into injury domized intervention study targeting players with previous injuries
prevention. Future research should therefore focus on pit- or reduced function. Am J Sports Med. 2008;36:1052-1060.
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ACKNOWLEDGMENT 19. Fuller CW, Ekstrand J, Junge A, et al. Consensus statement on injury
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The authors thank the Royal Netherlands Football Associ- cer) injuries. Br J Sports Med. 2006;40:193-201.
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for injury in elite football: a prospective study over two consecutive
to thank Adam Weir, MD PhD, for his useful contributions seasons. Br J Sports Med. 2006;40:767-772.
to the production of this manuscript. 22. Hägglund M, Waldén M, Ekstrand J. Risk factors for lower extremity
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version or at http://ajsm.sagepub.com/supplemental. 23. Heiderscheit BC, Sherry MA, Silder A, Chumanov ES, Thelen DG.
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